Being the body part that is at most contact with surfaces, the ankle is prone to injuries. Essential for mobility, the ankle is subjected to accumulated stress and trauma from performing activities of daily living to enjoy recreational activities and playing sports. No wonder that 25,000 Americans experience sprained or twisted ankle per day, and this is the least of all possible injuries that can affect the ankle. Moreover, about 2 million youth who play organized sports in the United States will sustain an ankle sprain at some point in their training.
The ankle joint is a hinged joint capable of total range of motion. However, its primary function is to execute an up-and-down movement (plantarflexion and dorsiflexion, respectively), necessary for walking and running. Capsule-ligament complexes guard its four surfaces (i.e. front, back, inner, and outer surfaces) against trauma and help to maintain an upright posture and carry weight. When mechanical forces from trauma and sport injuries exceed the tensile limits of the ankle joint capsule, sprain ankle occurs. In high-energy impact traumas, ankle fracture is unpreventable.
When talking about ankle injuries, both sprained ankle and ankle fractures are commonly mentioned. They are also the most common ankle injuries present in the emergency department. Are these two conditions the same? Is a sprained ankle a prerequisite for an ankle fracture? Can you have both at the same time? This article will discuss both common ankle injuries and will shed light on how these are managed and treated.
There are several mechanisms of injury that can lead to an ankle sprain, but the most common one is getting a twisted ankle from the inversion-type twist of a foot injury. Up to 85% of ankle sprains are inversion sprains of the lateral (outer side) ligaments. Simply put, a person losses balance with most of his weight rolling onto the outer edges of the foot. This is then followed by pain and swelling.
When barefoot, the sense of position of the foot is precise. However, this sense of position is distorted with the presence of footwear, particularly those made for organized sports.
Multiple sprained ankles are common among those people with general physical deconditioned bodies, particularly the elderly and those with a sedentary lifestyle. Decreased proprioception (position sense in space), decreased muscle strength, and lack of muscular coordination are considered risk factors for multiple sprained or twisted ankles.
On the other hand, unexpected factors like high-impact injuries can also exceed the tensile limits of the joint capsule and ligaments, leading to sprained or twisted ankles.
History of the mechanism of injury (usually inversion-type twist injury) is central to diagnosis. A sensation of tearing or a popping sound may be described. Generally, a person with sprained ankle can still walk, albeit the pain is apparent. In case of ruptured ligaments, rapidly-expanding swelling and bruising may occur. Numbness, complaints of “cold foot”, and motor deficits signify neurovascular compromise.
Sprained ankles can be classified into three based on degree of ligament tearing, degree of swelling, extent of functional loss, and ability to bear weight.
For acute isolated ankle sprains which were adequately treated, prognosis is excellent. Sprained ankle recovery time in up to 85% of patients is between 2 weeks to 36 months, with most gaining full recovery within the first 6 months. On the other hand, the risk for re-sprain is common in 1/3 of cases within between 2 weeks to 96 months.
Treatment and Management
So, what to do with a sprained ankle? The approach is geared towards pain reduction, restoring of range of motion and strength, and prevention of complications. Foot x-ray and MRI may be requested to visualize the extent of the injury. In the first three days, rest, cold compress, and elevation should be done to control swelling, pain, and spasms. Pain medications can be given. In some cases, ankle braces may be utilized.
Ankle fractures result from a direct blow to the foot and the same mechanisms which can lead to a sprained ankle. The most common cause is trauma. Careful examination should be done as some fractures do not present with obvious or gross deformity and can mimic sprained ankle.
People at risk for fall are considered to be more susceptible to fractures. Osteoporosis and old age are other considered risk factors. Ankle fracture is common among males, owing to participation in high-risk activities like sports and racing.
The onset of pain is acute, sharp, and localized. Deformity and bruising may or may not be present. Swelling is also apparent. Point tenderness can be also palpated at the site of fracture. Sometimes, upon palpation, crepitus and discontinuity can be detected.
With early diagnosis and prompt initiation of treatment, the prognosis can be improved. This is, of course, affected by the type of fracture and other associated injuries. Open ankle fractures will always have a poorer prognosis when compared to closed ankle fractures.
In isolated cases, bracing and casting may be applied for 4-8 weeks, depending on the evaluation and subsequent monitoring.
Treatment and Management
The goals are same as those with sprained ankles. In the pre-hospital area, the foot must be stabilized in a neutral position with the help of makeshift splints. Open fractures should be covered with wet sterile gauze. Assessment for further traumas should be done.
In the hospital, imaging will be requested. Depending on the result, the options range from closed reduction and splinting to surgery. Neurovascular complications are prevented with careful monitoring. For grossly infected wounds, antibiotics are initiated. Pain medication and comprehensive rehabilitation programs are integral parts of the management.
Accidents and sport injuries remain to be an important cause of trauma and hospitalization. Among them, ankle injuries are more common. Ankle sprain and fracture are two different types of injuries, although they can co-exist. Careful examination is needed to rule out fracture in patients presenting with sprained ankles, as it requires more intensive management.
Prognosis and recovery time of sprained and broken ankles are significantly improved by early diagnosis and prompt interventions. Early and correct stabilization of affected foot, pain management, and surgical options are the keys to managing these patients. In short, a good rehabilitation program with the help of orthotics and other mobility aids like knee walkers or scooters help to restore mobility earlier.
- Starkey, C. et. al. 2010. Examination of Orthopedic and Athletic Injuries 3rd E.A Davis Company. Philadelphia.
- Waterman BR, Owens BD, Davey S, Zacchilli MA, Belmont PJ., Jr The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010;92(13):2279–2284.
- van Rijn RM, van Os AG, Bernsen RM, Luijsterburg PA, Koes BW, Bierma-Zeinstra SM. What is the clinical course of acute ankle sprains? A systematic literature review. Am J Med. 2008 Apr;121(4):324-331.e6. doi: 10.1016/j.amjmed.2007.11.018. PMID: 18374692.